San Francisco Marin Medical Society Blog

Covered California Plan Specific Information for San Francisco

As of April 2014, 289,021 individuals have enrolled in health plans through Covered California, California’s health benefit exchange. Of those, a majority were eligible for federal subsidy.

A wide array of new Exchange-based insurance products have been offered by 5 participating health insurance companies in San Francisco. Additionally, federal law requires that every plan offered through Covered California also be offered outside of the Exchange (called “mirror” products), with the same benefits, premiums, and provider networks.

The San Francisco Medical Society has pulled together some key facts and detailed information about the health plans participating in Covered California.

Key Facts

Covered California does not contract directly with physicians, hospitals, or other providers. All plans contract directly with providers and the terms of those contracts—financial and non-financial—are proprietary to each plan.

The ID cards of all patients who purchased a plan sold through Covered California are co-branded, displaying the logo of the health plan and the logo of Covered California.

Beyond the required coverage of essential health benefits, the products offered to group purchasers are not required to have identical networks or benefits as those offered to individuals.

Anthem is the only plan that has a tiered hospital network. In the EPO network, enrollees have a lower out-of-pocket cost I they use Tier 1 hospitals (“Preferred Network”). Tier 2 hospitals are in network, but members have higher cost-sharing when using these facilities. Anthem reports EPO physicians were selected for the network based in part on a history of referring primarily or exclusively to Tier 1 hospitals.

Health Net reports its PPO network includes 44,000 physician. This network is used for all of Health Net’s PPO plans, regardless of where they are purchased. Participation terms for physicians are the same for both Exchange and mirror products.

Kaiser Permanente reports a network of over 14,000 physicians, covering all specialties, and 36 licenses acute care hospitals. The entire network is available to all individuals, regardless of plan type.